Can Information Technology, Nursing and Informatics

Shape Operations? A Case Study

Session 167, February 13

, 2019

Michelle Machon, RN, MSN, Director, Clinical Ed., Practice & Informatics, Kaiser Permanente

Edwina Bhaskaran, RN, MSN, Division Director Clinical Informatics, CHI Texas Division

Edwina Bhaskaran

Michelle Machon

Has no real or apparent conflicts of interest to report.

Conflict of Interest

Journey

• Background: What makes this discussion unique? Or is it?

• It started with IT: The Technology & Approach

• The People Factor

• To get to the Process

Summary

• The Challenges

• Outcomes

• Recommendations

Agenda

• Demonstrate the advantages of information and technology,

informatics and clinical partnerships during an EMR

implementation

• Create a strategy for robust relationships with departments where

strong partnerships are not the norm

• Identify the opportunities within organizations for managing the

issues that arise within greenfield projects

• Apply their learning's to their own organizations as information and

technology, clinical informatics and nursing work together

• Identify the challenges of opening a “first of its kind” American

healthcare system in the Middle East

Learning Objectives

Clinical Applications Director

– IT Employee # 2

Clinical Informatics Director

– Nursing Employee # 1

Clinical Educator and Unit Manager

– Clinical Educator # 1

Introductions & Background

Case Study: Background and Mission

Replicate the First US Multispecialty Hospital Outside North

America

Cultivate a Sustainable Healthcare System

Support the Development of Local Healthcare Talent

Traditional Approach

“IT should never lead

operations”

People

Process

Technology

People

Process

Go-Live

First Patient

1. The Technology

Implementation Complexity

Operational processes are now embedded within

EMR more than ever.

In this case:

• EMR served as an “anchor” implementation project for the IT

Portfolio and for clinical operations

– Timeline & Strategy

– Integration

Focus on EMR Implementation

Greenfield EMR Implementation Goal

Existing Organization EMR Initiative Greenfield EMR Initiative

Existing Process Optimizing Process

Input

Process Establishment

Implementation Input

Operation Process &

Policy

Technology Variables

GOAL: Operational Optimization & Efficiency GOAL: Establish Operations

Initiative Objective:

Implementation of an integrated Electronic Medical Record system that supports hospitals future

vision for patient care and will serve as the foundation for future optimization (captured during

implementation).

Accomplished By:

 Use existing EMR as a point of reference

 Leveraging industry standards to establish interoperability standards and functions

 Rigorous documentation of implementation process, decisions, assumptions that will provide

historical background

Implementation

Input

Content for EMR Design

EMR Design/Build Inputs

 Process Flows

 Regulatory Information

 Operating Models

 Organization Charts

 Staffing Plans

 Policies and Procedures

 Scope of Services

 Physical Locations

 Determining IP vs. OP areas

 Specialties

 Clinical Documentation Standards

In a standard EMR

implementation,

hospitals have provided

services and many of

the information listed

already exist.

A different approach was required….

The EMR Design Process included six steps per workflow validation

session. Each session required approximately 22.25 hours per session in

preparation time. This yielded a 96 % validation rate.

Design Deliverables

EMR IT Workflow Validation Schedule

 Schedule of 149 sessions

EMR IT Workflow Validation Materials

 EMR IT Workflow Presentations

Strategy Session

 Documented decisions from Strategy

Sessions

Deviations

 Documented differences in the

sequence of which activities are

completed by an end user within an

application, or in the point of reference

system

Design Deliverables Under

Change Control

EMR IT Workflow Visios

 446 EMR IT Workflow Visios and a Table of

Contents listing co-dependent EMR IT Workflows

Business Operations Input Toolkit

 806 Business Operational questions that define

the design of the system

Functionality Matrix

 Reference document to show the Epic

functionality that will be used

Facility Organization Structure

 Document detailing departments, locations and

service areas

Design Deliverables

The most significant challenge to completion of the EMR build was lack of operational

resources and schedule maintenance. The EMR and operations teams re-visited SME

identification, schedule approach and overall process several times during the course

of Workflow and Content Validation.

Scheduling

 Established Operational Identification Owner (OIO) group to act as operational champions

for the EMR Validation Schedule

 Had dedicated EMR Scheduling Analyst to manage schedule and meeting invites

 Used Change Control process to track changes

EMR Validation Schedule Facts

 890 instances of session rescheduling

 487 (54.7%) rescheduled sessions due to business

operations availability

 305 (34.3%) rescheduled sessions due to other EMR team

changes (usually shortening of sessions)

 51 (5.7%) rescheduled sessions due to follow up not being

completed on time

 33 (3.7%) rescheduled sessions due to EMR Project Team

availability

 14 (1.6%) rescheduled sessions due to other reason

2. The People

• The most crucial success factor for EMR implementations is

operational involvement and input.

• When the EMR Implementation commenced the following

individuals provided operational involvement:

Let’s talk about people…

Medical Informatics Director

Clinical Informatics Director

Chief Nursing Officer

Chief Medical Officer

Pharmacy Director

Administrative Services Director

Revenue Cycle Director

Finance Director

……that’s it!

• 200 design sessions back at Main Campus to prepare the on site

SMEs with a “frame of reference”

Process Framework

• The IT strategy was based on replication from reference

US site

• Became evident that answers were required to questions

that the newly hired clinicians had not considered.

• As the implementation progressed, the differences were

evident:

– Cultural

– Regulatory

– Facility differences

– More complex issues such as

• Anglicized spelling and date format

• DNR status

• Patient naming convention

• Fasting during Ramadan.

The Relationship Begins…

This could have caused friction

however….

• The key clinical and informatics stakeholders

realized that this was an opportunity to form

innovative collaboration avenues and they

took advantage and respected the direction IT

was bringing to the clinical staff

• Information Technology adapted to provide

flexibility while meeting implementation

timelines.

Evolution of a Partnership

• Operational Resources were sought with these

skills

 With local operational clinical experience

 With Main Campus clinical and IT Experience

 With EMR experience

 With Project Management experience

Resources Skill Mix

• Back in the States

– SMEs from every area were referred to daily

• From external local organizations

– Other hospitals

– Payors

– Regulators

More Partnerships…

3. The Processes

Operational Questions Examples

Scope of Practice

What is the scope of practice for

Physician Extenders and Associate

Physicians?

Scope of Services

What types of organ transplants do you

plan to perform?

Do any of these types require specialized

units? How often do you expect to be

doing these transplants ?

Patient Flow

Where will direct admission patients

arrive in the hospital? A registration

desk, the ED or directly on the floor?

Will this change based on acuity or

time of day?

Policy

Will a second signature (not a co-sign) for

specific medications (i.e. antibiotics) from

infectious disease be required? If not, will

Pharmacy restrict the ordering of certain

medications to specific medical specialties

(Infectious Disease)?

1. IT generated “design questions”

2. Needed a forum for these discussions which

became a multidisciplinary committee

responsible for the clinical decisions needed

“Informatics Clinical Advisory Group

(iCAG)

Example:

- “how often will you be reassessing your

patients in pain”

- “how often are you documenting on patients

in restraints”.

A Process to get to the Process

The options were trifold:

– let iCAG decide the processes,

– look to the evidence

– reach back to the main campus in the

States.

All three of these were utilized

 IT drove timelines, deadlines and

the project plan in general.

Operational Process Evolution

The Challenges

Challenge:

The local cultural, regulatory and legal

environment prevented a replication of the US

processes in the UAE

Solution:

Every single US process, document, order set

and workflow had to be touched and revisited

for the environment of the new facility.

Different processes “in-country”

Challenge:

– Only IT workflows had been documented

Solution:

Utilizing the index from a

standard nursing textbook and

the IT workflows, the basis of

nursing operations was formed.

Lack of clinical workflows

Challenge

“Bigest Bang” go live:

- All Clinical Applications, including the EMR

- All Medical Equipment + Device Integration

- All hospital policies & procedures, job orientation,

department orientation.

- Everyone was onboarding together, at the

same time.

Solution

A highly coordinated operations training plan

orchestrated by the IT PMO

Multiple Workstreams

Challenge:

The original construction timeline elongated

and so did the correlating IT implementation/

EMR build. New employees were onboarded

during these delays and there were challenges

with these new SMEs asking for new iterations

of the formal design

Solution:

Workflows that were developed were placed

under “change control” and incorporated into

the IT change control process

Extended timeline and changes

Resources eventually came but…

The EMR Team ran monthly sessions for new hires as an introduction

to the EMR, including work-to-date to design, build, test the EMR

system, policies and procedures related to workflow and/or content

changes, and related IT PMO processes.

Approach

Audience

Type of Orientation

Physicians (Chairs)

 One-on-One Meeting

 Frequency: As needed

 Topics Covered:

o EMR Overview

o Demonstration of related Epic functionality

o Governance and Change Control Process

Physicians (Non-Chairs),

Nursing Directors, Finance

Directors, Department

Administrators

 “Introduction to EMR” Session

 Frequency: Monthly

 Topics Covered:

o EMR Overview

o Demonstration of related Epic functionality (breakout session)

 Governance and Change Control Process

Managers, Analysts

 None

Tools / Supporting Documentation

 Powerpoint Presentation

 Epic System Demonstration

 Access to EMR Sandbox

 EMR IT Workflows

 Validation Session Materials

 EMR Decisions & Assumptions

Documentation

 Epic Glossary

 Epic E-Learning

Challenge:

– frontline staff were not immediately using the

system so knowledge gained was often lost

– learning multiple business/clinical apps at once

meant the caregivers were often confused/ had

cognitive overload

Solution:

– Hundreds of end-to-end multi-disciplinary

walkthroughs

– Post go-live round the clock shoulder to shoulder

support, geographically located in depts

– Peer to peer (super-user) learning was vital.

Training

70+ Applications to train on

Challenges

– After opening- clinicians wanted nearly every

process to be adapted, changed or

redesigned

Solutions

– Strong leadership commitment to a

governance process

Post go-live Change requests

Eventually worked with IT to put a

change management process in place…

The End Result

• Trust

– Operations needed to rely heavily on IT expertise.

– IT needed to rely heavily on operations to keep the

implementation moving.

• Collaboration

– Approach needed to be modified several times over

the course of the implementation to facilitate changes

to hospital operations (e.g. organ donation)

• Open (Effective) Communication

– Welcomed and acknowledged risk and issues

Partnership

• Facility opened HIMSS stage 7 enabled

• Virtually “paper” less system

• IT Implementation enabled hospital operations

and provided a foundational system for

optimization

Result

The Recommendations

• View go-live as a “phase”

• Plan resources to projected patient

volume

• Create an agile governance process

Recommendations from IT

• Create a robust Mock Operations

plan

• Mirror your “Sandbox” environment

as close to reality as possible

• Remember that “perfection is the

enemy of progress” (Winston

Churchill) .

Recommendations from Nursing

• Maintain your strategic partnerships

• Create a strong clinical governance

process pre-opening.

• Do not be “married” to your build.

• Set very clear expectations with your

Clinicians

Recommendations from Informatics

• Michelle Machon, RN, MSN

• Edwina Bhaskaran, RN, MSN

Please complete your evaluations!

Questions